Ruminations by a non-academic general surgeon from the heart of the rust belt.

Friday, May 23, 2008

Never? Really?

This case has been modified for obvious reasons.

When I was an intern, there was a patient who came in for gastric bypass surgery. This was in 2001 before reimbursement for bariatric surgery took a dive, and we usually had four or five patients at various stages of recovery from Roux-en-Y bypass in the hospital. This patient was a 35 year old male who weighed over 700 pounds. That's 700 pounds. His BMI was greater than 100. He had all the usual co-morbidities one would expect; diabetes, severe sleep apnea, pulmonary hypertension, etc.

Because of his body habitus, his bypass was done via an open laparotomy. Unfortunately, his ventilatory parameters were suboptimal at the end of the case and anesthesia kept him intubated, given the difficulty of placing the tube under duress. He never weaned. He acquired pneumonia. The tube stayed in for weeks. Ultimately, a tracheostomy was placed and he was eventually transferred to a long term care facility. His recovery was long and slow but he finally went home after several months of rehab. He lost close to 400 pounds over the next several years. His diabetes resolved. His heart function improved. And then the hospital and the attending physician (and, by extension, all the residents involved in his care) received a notice from a plaintiffs lawyer notifying of intent to sue for a ridiculous sum of money....

In the immediate post-operative period, the patient was vented and bed ridden in the ICU. Nursing records make note of skin breakdown and eventual development of a sacral decubitus ulcer, despite the use of an air mattress and preventative maneuvers to shift him every few hours. The chart describes 6,7, and sometimes 8 people being required to assist in rolling him one way or the other. Appropriate dressings were applied. Necrotic tissue was debrided when necessary. It never progressed to the point of being a septic wound. During the recovery phase, a plastic surgeon covered the resultant open wound with a tissue flap.

And this is what the suit is about. A decubitus ulcer in an extremely ill patient who weighed so much that the entire ICU staff was needed to roll him in such a way to take pressure off the skin and subcutaneous tissues of his ass. Well, the Herculean efforts of dedicated nursing personnel and doctors wasn't enough in this particular case..... But now we have "never events" as described by Medicare and Cigna and soon to be many other insurance companies. Line infections and UTI's and delirium and c diff colitis and decubitus ulcers aren't supposed to happen anymore. It's the doctor's and nurse's fault. Coincidentally, this lawsuit was posted shortly after this new designation came out. Never events. Is this the sort of vocabulary we want to be using? Never? I can't wait for the avalanche of lawsuits soon to be coming down the pipeline for the elderly lady with pneumonia who develops c diff or the old guy who goes into delirium after his Whipple....

correct me if i'm wrong, but this just highlights the highly litigative nature of the US healthcare system. the patient will get help to sue whenever possible. i was told this might be possible to prevent with better doctor-patient communication. most law suits can be prevented with appeasement on a hospital and doctor level.

but who knows? the reasons behind the discontentment might be many. a mean comment from one of the ICU staff whilst moving? an overheard unkind remark on the kind of efforts they had to go through just for him? the need for money which had been spent on the bypass op?

Excellent post. As we see more morbidly obese patients, we have to face the greater likelihood that they will develop complications such as decubitii. We're also in the unenviable position of having to evaluate their medical risk without the benefit of imaging studies, etc., when these studies can't be done on a 400+ pound person.

I'm very up-front with morbidly obese patients. "Because of your weight, I can't order a CAT scan to see if your breathlessness is being caused by a blood clot...." I spend a lot of time documenting the issue in the medical record, too. It's a lot of extra trouble, and at the end of the day I have to ask myself: "Is it my fault he's so fat?" Is that unkind?

This is the sort of thing that makes me want to tear out what's left of my hair, and which no doubt explains its current color. My reaction, when I saw those new rules, was that exactly this would happen. It's awful.

At some point, we in the medical profession are going to have to stage some sort of Boston Tea Party type of event and reclaim our profession from all the know-it-all bureacrats, or else simply accept the inevitable death of that profession.

Perfect example of how this system will go to hell in a handbasket because of these rules. Those who need emergent care are going to get bounced from hospital to hospital because staff physicians suddenly don't feel "comfortable" taking care of a patient with multiple comorbidities who might develop a "never event." Once word of this case spreads and the risks of treating 700 lb patients who are more likely to develop "never events" spreads, guess how often a 700 lb patient is going to get an elective surgery such as this. Can you say ... "never"?

This is truly exasperating. I loved White Coat's response. Our legal system is perverse, and "quality rules" appear to be designed by people who have no understanding of medicine.

The "never events" rule will end up hurting the patients it purports to protect - yet another policy designed to feed the monster of unintended consequences. This all stems from bureaucrats trying to make black and white out of gray.

We could also be in a situation where that obese patient could/should sue the hospital if an adverse event occurs because the hospital did not have the facilities to adequately treat his/her condition.

Just because someone is of a particular size does not mean its ok that their medical treatment is compromised.

I think ultimately its the manufacturers that need to be pressured to create machines for all sizes. However, it would be the doc or hospital that receives the lawsuit.

Syna-Certainly, it is important to make sure one's health care is not compromised by one's particular sex, race, or body habitus. However. Personal accountability is a still a major component of how society agrees to ration its resources. If you're lazy, you won't get paid well. If you don't do your homework, you won't get into Harvard. If you let yourself balloon to gargantuan weights, your likelihood of receiving perfect health care without a hitch is going to be suboptimal. Blame the manufacturers? Give me a break. At some point we have to look ourselves in the mirror.

I don't profess to have an answer for the problem in this particular setting, but in the limited setting of our field of IVF, there is clear evidence that when a patient's OWN wallet is on the line, they suddenly find the will power to be self-accountable. For example, my frank discussions with overweight patients is that I can help them get pregnant regardless, but if they could get to a healthier weight, I can do it faster, less expensively and less invasively. Those who have unlimited insurance coverage tell me to help them no matter what it takes, without motivating themselves to lose weight. Those who pay out of pocket diligently work with me to control their weight, often losing 40-50# before we even start fertility treatment. Human nature is such that when the rules are in place to encourage taking responsibility for ones own outcome, things are overall better for everyone. When the rules in place give no incentive for assuming personal responsibility, then everyone suffers.

I remember around mid 1990's being one of the nursing assistants called from another unit to the ICU to help the RN's roll a similar patient every two hoursThe ICU RN's became very tired after a few shifts of rallying the troops on just their unit that manager devised a plan for a turning team for a couple weeks that met every 2 hours in her room.

We also needed 6 to 8 people to turn her. After she could help turn herself it still took sometimes 4 people to do a bedchange for stool for example as her leg needed to be held up to get it clean down there. And it took about 2 people to hold her leg up for more than 30 seconds.

They had a bed that was industrial strength but didn't have a airmatress but she could get it up into a chair position for bit until her breathing became too hard presumabley from the weight placed on her lungs by her weight

She stayed over a month in the ICU I recall because of an awful large and quite deep decubitus ulcer. They had not done these surgeries for years ( a decade maybe?) and she was one of the first to be done as the surgeons must have thought why not since if she doesnt get surgery she'll die of obesity complications pretty soon anyways.At first they only did the largest of the patients at first.

Now I work as a RN and I am amazed at the patients who are much smaller that have this surgery done. I know a woman who was quite well off and convinced that this was the only way for her moderate obesity to be cured. But her attempted exercise treatment failed but she only played tennis 3 times a week. Not exactly the type of excercise program I envision being an honest attempt to take it off with excercise first.

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